MEDICINE - Medical Journal has no space for criticism of Hepatitis C report

by News Weekly

News Weekly, March 11, 2000

The prestigious Medical Journal of Australia has advised a doctor who conducts a large practice in treating heroin addicts, that it was unable to publish a letter on the prevalence of Hepatitis C among injecting drug users, due to lack of space.

The Deputy Editor of the Medical Journal of Australia, Dr Ruth Armstrong, advised Dr Stuart Reece that his letter could not be published, after it had been "carefully considered by the editorial committee."

Dr Reece had critically analysed an article which appeared in the MJA on January 17 this year, along with an accompanying editorial, which suggested that among users of needle exchange programs, the incidence of Hepatitis C was in decline.

The study reported in the MJA was conducted by Drs M.A. MacDonald and Alex Wodak, and suggested that the prevalence of Hep C among injecting drug users had fallen between 1995 and 1997. (Hepatitis C is an incurable viral disease, which ultimately kills many of those who contract it.)

The clear implication of the study was that the needle exchange program had caused the decline of Hep C among intravenous drug users, and the accompanying editorial in the Medical Journal of Australia described its findings as "encouraging", although possibly affected by "selection bias".

If true, this would contradict numerous earlier studies which had shown that Hep C is rampant among injecting drug users, including those who use needle exchange programs.

Dr Reece drew attention to a key problem with the study, that the population sample used for the 1996-97 survey was different from that which had been used in 1995-96, to a point that invalidated its findings.

He said, "The observed decline in Hepatitis C virus prevalence occurred only in the years 1995-96; no additional effect was noted in 1996-97.

"As the authors rightly state, the difference between the two samples was marked. The 1996 sample was 150 per cent larger than the 1995 sample, and the addition occurred disproportionately in the youngest cleanest group (212 per cent rise in the teenagers, and 183 per cent rise in the new users [with less than three years' of injecting drug use].

"This 'apparent' decline then disappeared in 1996-97 when the samples were more directly comparable."

He asked, "How does recruiting younger and less experienced addicts translate into a victory over Hepatitis C virus prevalence?"

Dr Reece commented that "given the extreme infectivity of the Hep C virus, it is difficult to foresee radical control of this epidemic without a true decline in IVDU [intravenous drug use].

"Direct approaches to this issue are at present markedly absent from the indirect measures usually espoused under the 'harm minimisation' rubric; indeed, 39-70 per cent of the respondents to our recent small surveys felt that governments actually encourage (as well as discourage) drug use - the sure nemesis of any benevolent medically informed drug policy."

Dr Reece concluded by suggesting that the Medical Journal might care to examine studies which had been conducted into the effectiveness of naltrexone in the treatment of heroin addiction.

In a recent submission to the Prime Minister on drugs, Dr Reece pointed out that naltrexone works by binding to the opiate receptors and blocking them. The effect of this is to lengthen the period which an addict can go without heroin after undergoing detoxification, and therefore gives both patients and medical staff more time to treat the underlying causes of drug addiction.

Dr Reece says that "naltrexone reduces the craving for opiates which many find overwhelming, or allowing patients, when they do consider using them, to think about drugs in a more reasoned deliberate way, rather than automatically succumbing to the erratic obligatory compulsion to score which characterised their using life.

"Moreover, because it is active for about three days, naltrexone means that patients can no longer effectively sabotage their clean state in 15 minutes. This gives the patient's social network, carers and counsellors a window of opportunity, a safety net period in which to intervene to assist them to deal with the issues which confront them."

Dr Reece has written that naltrexone is not a "miracle cure" for heroin; but for most, it is "a very good first step, the beginning of the path to freedom from the compelling nightmare of drugs.

"Heroin affects the whole of one's life, and some say even one's very soul. Naltrexone is only a small beige tablet. Naltrexone is not addictive and produces no sedation. The choice of naltrexone therapy is a choice for an opiate free lifestyle, and works best in a completely abstinent drug free life.

He concluded, "The challenge to the community is to maintain the patients in a sober straight lifestyle, lest by relapsing, they risk social destitution and death. Counselling and family support are essential."